Registered Nurse RN Inpatient Case Manager – Remote from Texas at UnitedHealth Group

About the position

Opportunities at WellMed, part of the Optum family of businesses, emphasize the belief that all patients are entitled to the highest level of medical care. As a member of our team, you will share a passion for helping people achieve better health. We offer a variety of roles, including positions for physicians, clinical staff, and non-patient-facing roles, allowing you to make a significant difference in the lives of others while discovering the meaning behind our motto: Caring. Connecting. Growing together. The RN Case Manager II – Inpatient Services is responsible for performing onsite or telephonic clinical reviews of inpatient admissions in various healthcare settings, including acute hospitals, rehabilitation facilities, LTAC, or skilled nursing facilities. This role involves actively implementing a plan of care that utilizes approved clinical guidelines to ensure a smooth transition and continuity of care for members as they move to an appropriate lower level of care. Collaboration is key, as the case manager works closely with hospitals, physician teams, acute or skilled facility staff, ambulatory care teams, and the members and their families or caregivers. The case manager coordinates care from admission through discharge, participating in Patient Care Conferences to review clinical status, update discharge needs, and identify members at risk for readmission. In this role, you will independently collaborate with the Interdisciplinary Care Team (ICT) to establish individualized transition plans for members. You will serve as the clinical liaison with hospital staff and perform clinical authorizations for inpatient care using evidence-based criteria. The case manager will conduct various types of clinical reviews, document medical necessity, and communicate effectively with facility staff and members to assess discharge needs and formulate discharge plans. Additionally, you will manage an assigned caseload efficiently, demonstrate knowledge of utilization management and care coordination processes, and maintain accurate documentation to comply with organizational requirements. This position also requires maintaining current licensure and hospital credentialing, as well as adhering to regulatory requirements and clinical guidelines.

Responsibilities
• Independently collaborates effectively with Interdisciplinary care team (ICT) to establish an individualized transition plan for members.
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• Serves as the clinical liaison with hospital, clinical and administrative staff and performs a review for clinical authorizations for inpatient care utilizing evidenced-based criteria.
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• Performs expedited, standard, concurrent, and retrospective onsite or telephonic clinical reviews at in-network and/or out-of-network facilities.
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• Documents medical necessity and appropriate level of care utilizing nationally recognized clinical guidelines for all authorizations.
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• Interacts and effectively communicates with facility staff, members, and their families to assess discharge needs and formulate discharge plans.
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• Identifies member’s level of risk by utilizing Population Stratification tools and communicates the member’s transition discharge plan with the ICT.
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• Conducts a transition discharge assessment onsite and/or telephonically to identify member needs at the time of transition to a lower level of care.
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• Manages assigned case load in an efficient and effective manner utilizing time management skills.
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• Demonstrates exemplary knowledge of utilization management and care coordination processes as a foundation for transition planning activities.
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• Confers with UM Medical Directors and/or Market Medical Directors on a regular basis regarding inpatient cases and participates in department huddles.
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• Enters timely and accurate documentation into designated care management applications to comply with documentation requirements and achieve audit scores of 90% or better on a monthly basis.
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• Adheres to organizational and departmental policies and procedures.
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• Takes on-call assignments as directed.
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• Maintains current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms.
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• Refers cases to UM Medical Director as appropriate for review for cases not meeting medical necessity criteria or for complex case situations.
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• Monitors for any quality concerns regarding member care and reports as per policy and procedure.

Requirements
• Bachelor’s degree in Nursing and/or Associate’s degree in Nursing combined with 4+ years of experience.
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• Current, unrestricted RN license required, specific to the state of employment.
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• Case Management Certification (CCM) or ability to obtain CCM within 12 months after the first year of employment.
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• 4+ years of diverse clinical experience in caring for acutely ill patients with multiple disease conditions.
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• Ability to read, analyze and interpret information in medical records and health plan documents.
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• Knowledgeable in Microsoft Office applications including Outlook, Word, and Excel.
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• Reliable transportation that will enable travel to client and/or patient sites within a designated area.
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• This position requires Tuberculosis screening as well as proof of immunity to Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, and Pertussis.

Nice-to-haves
• 3+ years of managed care and/or case management experience.
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• Experience working with psychiatric and geriatric patient populations.
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• Knowledge of utilization management, quality improvement, and discharge planning.
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• Bilingual (English/Spanish) language proficiency.
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• Proven ability to problem solve and identify community resources.
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• Proven planning, organizing, conflict resolution, negotiating and interpersonal skills.
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• Proven ability to utilize critical thinking skills, nursing judgment, and decision-making skills.
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• Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously.

Benefits